There are many problems associated with the use of articulating antibiotic cement spacer blocks and articulating components in the two-stage treatment of total hip replacement and total knee replacement infections. These include loss of motion during and after treatment, bone loss, generation of cement debris, inadequate dosing of cement with the appropriate antibiotic, and biologic failure. Forty-four patients with 54 consecutive periprosthetic hip and knee infections (31 septic total knee arthroplasties and 23 septic total hip arthroplasties) had treatment with a modified two-stage reimplantation protocol using articulating components made of antibiotic-cement-only prosthetic components and antibiotic-cement-covered prosthetic components between January 1995 and May 2002. Second-stage revision, after six weeks of parenteral antibiotics, was completed an average of 84 days after the first stage. A minimum two-year followup after final treatment is evaluated. One of the 23 total hip replacement infections persisted or recurred with the original organism(s) after treatment (95.7% success) as did two of the 31 total knee replacement infections (93.5% success). Combined success rate was 94.4%. This modified treatment method incorporates early range of motion during first-stage treatment with articulating components that provide local high-dose elution of broad-spectrum antibiotics, provides the flexibility of customizing the antibiotic cement components with culture-directed antibiotics, and results in a high biologic success rate.
[Show abstract][Hide abstract] ABSTRACT: Periprosthetic infection about the knee is a devastating complication that may affect between 1% and 5% of knee replacement. With over 79 000 knee replacements being implanted each year in the UK, periprosthetic infection (PJI) is set to become an important burden of disease and cost to the healthcare economy. One of the important controversies in treatment of PJI is whether a single stage revision operation is superior to a two-stage procedure. This study sought to systematically evaluate the published evidence to determine which technique had lowest reinfection rates.
A systematic review of the literature was undertaken using the MEDLINE and EMBASE databases with the aim to identify existing studies that present the outcomes of each surgical technique. Reinfection rate was the primary outcome measure. Studies of specific subsets of patients such as resistant organisms were excluded.
63 studies were identified that met the inclusion criteria. The majority of which (58) were reports of two-stage revision. Reinfection rated varied between 0% and 41% in two-stage studies, and 0% and 11% in single stage studies. No clinical trials were identified and the majority of studies were observational studies.
Evidence for both one-stage and two-stage revision is largely of low quality. The evidence basis for two-stage revision is significantly larger, and further work into direct comparison between the two techniques should be undertaken as a priority.
"Fifteen studies evaluated the revision procedure by means of the Harris hip score.11,16,47,48,50,57–59,61,64,68–70,77,79 Twelve studies did not use a standardized scoring system in evaluating patients postoperatively.13,51,52,55,60,63,65,66,71–73,80 Four studies used the Merle d’Aubigné–Postel score.49,54,56,75 "
[Show abstract][Hide abstract] ABSTRACT: Two-stage revision is regarded by many as the best treatment of chronic infection in hip arthroplasties. Some international reports, however, have advocated one-stage revision. No systematic review or meta-analysis has ever compared the risk of reinfection following one-stage and two-stage revisions for chronic infection in hip arthroplasties.
The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Relevant studies were identified using PubMed and Embase. We assessed studies that included patients with a chronic infection of a hip arthroplasty treated with either one-stage or two-stage revision and with available data on occurrence of reinfections. We performed a meta-analysis estimating absolute risk of reinfection using a random-effects model.
We identified 36 studies eligible for inclusion. None were randomized controlled trials or comparative studies. The patients in these studies had received either one-stage revision (n = 375) or two-stage revision (n = 929). Reinfection occurred with an estimated absolute risk of 13.1% (95% confidence interval: 10.0%-17.1%) in the one-stage cohort and 10.4% (95% confidence interval: 8.5%-12.7%) in the two-stage cohort. The methodological quality of most included studies was considered low, with insufficient data to evaluate confounding factors.
Our results may indicate three additional reinfections per 100 reimplanted patients when performing a one-stage versus two-stage revision. However, the risk estimates were statistically imprecise and the quality of underlying data low, demonstrating the lack of clear evidence that two-stage revision is superior to one-stage revision among patients with chronically infected hip arthroplasties. This systematic review underscores the need for improvement in reporting and collection of high-quality data and for large comparative prospective studies on this issue.
"If adequate host bone is present, reconstruction with host bone can be done in the setting of one- or two-stage  reconstruction. While two-stage reconstruction with antibiotic spacers may be successful in eradicating infection in up to 95% of patients   , traditional reconstructive techniques fall short in the face of segmental bone loss or host factors that preclude use of host bone for reconstruction . Custom devices substituting for severe segmental bone loss after infected THA provide an opportunity at limb salvage, with maintenance of leg length, soft tissue tension, direct antibiotic elution into the tissue bed, and possibility for improved functional status/ambulatory capacity. "
[Show abstract][Hide abstract] ABSTRACT: Introduction. Total hip arthroplasty (THA) infections with severe bone loss pose significant reconstructive challenges. We present our experience with two-stage hip reimplantation using an intramedullary, antibiotic-impregnated nail. Methods. Three patients with infected THA with severe proximal femoral bone loss (Mallory type IIIB or greater) were treated using a custom antibiotic spacer. Clinical outcomes and any complications were recorded. Average followup was 49 months from final reimplantation. Results. Mean age at spacer placement (stage 1) was 53 years. The mean Harris Hip Score at final followup was 80. Two patients had asymptomatic heterotopic ossification, and one patient had a 2 cm leg-length discrepancy. Conclusions. A custom intramedullary nail antibiotic spacer is a reliable option in the staged management of the infected THA with severe proximal femoral bone loss. Benefits of this technique include limb salvage with maintenance of leg length, soft tissue tension, and functional status.
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